Generalist solutions to complex problems: generating practice-based evidence - the example of managing multi-morbidity

Strengthening generalist practice has been mooted as part of the solution to emerging problems facing health systems [1‐3]. Generalism refers to a professional philosophy of practice deeply known to practising physicians but which is less well understood (and valued) by other stakeholders in the wider health care community. Two approaches to strengthening generalism can be envisaged. Firstly, a professional development approach would see leadership from professional bodies in advocating for change to support and enhance generalist practice. A number of international Colleges have started this work [2, 4]. We may complement and extend that work using a research-based approach: to develop evidence of if and when whole-person generalist care offers something different and better to other models of care (for example, condition-focused specialist care). The aim of this paper is to develop a framework to support this second route. We use a key challenge for health systems – managing multi-morbidity – as a critical case within which to describe our ideas. And finish by considering how the work might be used more widely to strengthen generalist practice and so contribute to improving the effectiveness of health care.

“The current care systems cannot do the job. Trying harder will not work, changing systems of care will” [5].

The need to ‘Think Differently’ about care for people with multi-morbidity is an identified priority for health systems across the world [6‐9]. Around, one in four people live with a long-term condition; the majority with more than one [9, 10]. 70% of health service spending in the UK, for example, is on dealing with long term conditions [6, 7]. Multi-morbidity is more common amongst deprived populations [10]. We face an ‘epidemic of multi-morbidity and rising complexity of health needs’ [6, 11] resulting from changing demographics and global circumstances. Tackling this problem is a major and urgent strategic priority.

There is a growing mismatch between the needs of populations of people living with complex, chronic illness [10]; and the resources offered by a health system that is focused on condition defined care^a[12]. Current strategies for managing long term conditions emphasise two elements: delivering interventions defined by evidence-based condition-specific protocols of best practice; and developing teams of multiple professionals to manage the level and complexity of demand thus created [13]. The goal is integrated, effective care [14]. Yet critical review of the current evidence of the impact of integrated care highlights demonstrable improvements in clinical governance (e.g. adherence to protocols), but little impact on patient outcomes or costs to health services [15]. The focus on organisational integration has produced limited benefit for individual patients [15]. However policy makers lack evidence defining high quality alternatives that achieve better patient outcomes.

The Word Health Organisation has called for work to refocus health care to recognise and address the health goals of individuals [16]; changing clinical practice from condition focused care to “individually tailored decision making” [17]. The challenge for health systems is how to develop a model of integrated care that is centred on the needs of the person, rather than the needs of the health system itself [6, 18, 19]). Medical generalism, or ‘expertise in whole person medicine’, has been proposed as a professional practice-based solution to the problem [2]. However generalism is a professional philosophy of practice [20], rather than the evidence-based model of care needed by policy makers and planners to support service re-design.

Roland & Paddison argued that if health systems are to tackle the challenge of multi-morbidity, clinicians need to be free to exercise professional judgement in their management of patients [21] – to go ‘beyond the protocol’. Recognising that professionals bring their own ‘evidence’ to the decision making process [22], which they integrate with evidence from scientific study to make an informed judgement. This role is core to the expertise of the generalist [1, 2, 20, 23].

Whilst authors have recognised the limitations of protocol-defined care [21, 24], as yet there is a lack of evidence to demonstrate that the professional judgement of generalist expertise delivers better outcomes (see Figure 1). Developing generalist solutions to complex problems such as multi-morbidity is an example of a ‘practice-to-evidence gap’ [25]. To date, work has focused on how to get evidence into practice – to address a perceived evidence-to-practice gap and encourage practitioners to use evidence. Our discussions recognise an alternative problem – a gap between the practice and the science, with a need to develop practice-based evidence [25] of the impact of generalist care.

To tackle this practice-evidence gap, we consider how to develop evidence of the impact of generalist practice. We view ‘doing generalism’ as an intervention and so use the Medical Research Council Complex Interventions framework as a guide to evaluating the approach [28]. We must therefore start with a definition.

In western communities, health needs increasingly reflect the rise in prevalence of chronic complex illness. We need to adapt health systems to meet this need; through providing a balance of generalist and specialist care [1, 16]. We have an increasingly detailed understanding of the pathology of the common chronic diseases facing our communities, and so of ways to intervene in the pathological process. Guidelines for care derived from ‘robust synthesis of clinical and economic evidence’ support optimisation of disease-focused care [24]. However, we lack an equivalent framework supporting generalist care. We lack practice-based evidence to demonstrate the utility and trustworthiness of generalist care alongside the better described specialist approach. We have discussed an example of improving care for people with multi-morbidity, but suggest that the approach may be of utility for a range of ‘complex problems’ and areas of diagnostic uncertainty for example, medically unexplained symptoms.

We have outlined an approach to address this practice-evidence gap based on action research principles. Action research for quality improvement is not a new concept in health care [35]; but evidence for practice is still traditionally dominated by experimental designs. Yet a number of sources are challenging a ‘drainpipe’ model of knowledge translation, which sees research evidence as a way to inform practitioners and policy makers what they ‘should’ be doing [25, 38, 39]. There has been a call for more critical examination of practice, based on the principles of participatory research and action learning, in order to support the translation of practice into an evidence base which contributes to the critical development, delivery and evaluation of quality care [25]. This is particularly appropriate when the expertise lies within the clinical community.

If this approach is to be successful, we need also to recognise and address the barriers to undertaking this sort of research - including issues related to funding, career progression for action researchers and support for dissemination. Critical implementation and evaluation of the GIA framework may also provide us with evidence of the value and limitations of action research for improving health care.

We thus describe a new framework to support the generation of practice-based evidence of the impact of individually tailored generalist care. We have evidence supporting the development of the component parts, but now seek to evaluate whether the framework can support change towards more person-centred care. Testing the framework is one goal for a new Special Interest Group (SIG) within NAPRCG (the North American Primary Care Research Group). The Generalism SIG was formed in 2011 to support the critical development, delivery and evaluation of generalist care within a modern managed health care context. It is an international collaboration with representatives from North America, Australia and Europe. Developing and implementing the GIA is one area of our work. We welcome comments, feedback and expressions of interest in joining us in this work.

^a We refer to ‘condition’ rather than ‘disease’ defined care since: health policy refers predominantly to long term conditions, rather than diseases; dealing with the management of a ‘condition’ that ‘warrants attention’ – for example hypertension – rather than a disease per se.

All are members of the NAPRCG Generalism Special Interest Group. JR holds a National Institute of Health Research Clinician Scientist Award supporting a body of work on Generalist Solutions for Complex Problems. GF was a member of the Royal College of General Practitioners (UK) Commission on Generalism.